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Attention Deficit and Hyperactivity Disorder (ADHD) Autistic Spectrum Disorder (ASD) Buddhi Stories Featured

From Tasmanian Devil to Mathematical Whiz

Master S first met the Neurokrish team (later to become the Trimed-Neurokrish team) about 6 years ago. Aged three years at the time, he was brought to us by his grandfather who had recovered fully from a stroke, under our care. S demonstrated clearly to us the features of both Autistic Spectrum Disorder (ASD) and Attention Deficit and Hyperactivity Disorder (ADHD). He refused to maintain eye-contact, engaged in fleeting social contact which was very poorly sustained and was yet to develop any language skills of note. More disturbingly, S was profoundly hyperactive and disruptive, so much so, that he could in a few moments literally tear apart a consulting or therapy room, when left alone. Needless to say, his mother was distraught, and his extended family members were dismayed. In our minds, S bore a striking resemblance to “Taz” the adorable but disruptive “Tasmanian Devil”, then a beloved cartoon character, much loved by the kids.

Taz was offered a combination of behaviour therapy, Neurodevelopmental therapy and family counselling. He was also prescribed medication to improve attention, stabilise his volatile moods and cut down his very disruptive behaviours. Over a 3 year period, our therapeutic relationship with Taz’s family evolved; together we walked many a milestone; his first words, his play school, kindergarden, and primary school. Therapeutic holidays from drugs during summer and winter vacations; the role of extended families, maternal and paternal; expectations of the many stakeholders, parents, both sets of grandparents, uncles and aunts; teacher and school interactions; our therapeutic relationship weathered these many storms. His GI problems responded to our Naturotherapy approaches; his limbs became dexterous and his fine motor skills including handwriting skills improved with Neurodevelopmental therapy and Ayurvedic massages. Thanks to sustained behaviour

therapy and parental counselling he became less disruptive, could follow parental instructions and began to sit for longer periods of time. His attendance and participation at school improved dramatically; his intuitive mathematical abilities started to shine; he learned to interact better with peers and teachers. Indeed, not only did he survive primary school, he had even topped his class in mathematics. Clearly Taz was endowed with “mathematical intelligence” that outstripped other “emotional and social” domains (see A Vital & Alternative Perspective To Enabling Potential).

Taz, with a combination of ADHD and ASD, was one of our most challenging child clients ever! Recently we met our “Taz” one final time, before he migrated with his family abroad. His evolved parents had declared his condition in the immigration visa application form and sought special assistance for him aided by a detailed summary from Trimed-Neurokrish.

Taz is still a little disruptive and impulsive, butts into conversations, slightly stilted in his speech, but we know he has come a long way. Our Trimed-Neurokrish Integrated approach judiciously combined medication and behavioural and neurodevelopmental therapy, with Naturopathy and Ayurveda, empowered the family with counselling, and awakened his “mathematical intelligence”, with progressive increase in his self-esteem. With this, his social interactions exude warmth and willingness to communicate. His onward life’s journey while abroad must follow the same trajectory.

We must admit that S’s remarkable progress was made possible by the wonderful therapeutic relationship our team had with his family. From S and his family we have learnt the importance of looking beyond terminology and the diagnostic label. Sustained therapy with vigilant monitoring and family and special school support, carry their own reward and hold hope for children, affected just like S. Prof. Dr. Ennapadam S. Krishnamoorthy

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Autistic Spectrum Disorder (ASD) Buddhi Stories Epilepsy & Seizures Featured

Bharath – Emerging From The Shell

Biography

By 9 months of age the infant showed regression in eye-contact and response to call. By the time the child was 1 year old, the father left home, never to return, but provided financial support from afar. Was he shirking his paternal role towards his child with developmental disability? But the well-educated mother took matters in hand, moved in with her parents for logistical and emotional support for the whole family, and devoted her time to Bharath, to quell his hyperactivity at two years and to push his delayed language acquisition to the next level. Paediatric consultations for guidance, regular speech therapy and early Montessori schooling saw Bharath settle comfortably in a mainstream school, with

age-appropriate range of receptive and expressive language, with reading and writing in place by 6 years of age. He continued to be a slow learner.

Was he shirking his paternal role towards his child with developmental disability?

However, the challenge for the family has been the inevitable behaviour problem of ASD – (differently wired!) which is often traced to poor sensory integration, resultant poor holistic perception, hyperactive emotional network with weak frontal lobe inhibitory commands to suppress the eruptions of uncontrolled energy. Bharath’s unprovoked emotional outbursts, with violence directed mainly against his mother (or in destroying objects), is partly an expression of internal hurt, as he is not amnestic of the event, and shows remorse for the behaviour in recent times. He insists on his mother’s undivided attention and spares her little time to devote to his elder sister. These outbursts are fewer over the past 1.6 years since he joined Vidya Sagar, as he receives multimodal therapy, is on regular anticonvulsant, antipsychotic medication and SSRI, and his energies have been channelled, with the focus on academics. He has cleared the Open School Board Examinations in Home Science, English and Computer Data entry, without scribe assistance, and is preparing for the Business Studies examination in October 2017. He will complete all five subjects required for the Board’s 10th Std. Secondary School Certificate in April 2018, when he does the bakery/painting examination – truly a most commendable effort!

With his self-esteem and self-confidence rising, we find Bharath come out of his shell and mingle socially with his peer group at school and with relatives and friends who visit their home. He is Secretary of the local Interact Club, has joined NCC as a cadet and follows cricket and movies on TV with keen interest. He tends to talk excessively, lacks discrimination and even reveals close family concerns to outsiders. The client had seizure disorder which is moderately controlled on medication. Currently he is on the following medication: Syrup Sodium Valproate Extended Release, Zolpidem (Non Benzodiazepine hypnotic), Aripiprazole (Aripiprazole is an antipsychotic preparation and helps control irritable behavior such as aggression, temper tantrums, and frequent mood changes in ASD).

Assessment Reports

The Clinical Specialists Observations –

An intact systemic examination. Neuropsychiatric Inventory reveals intact Higher Mental Function (HMF), reactive affect, normal intelligence and no focal deficit.

EEG Report :

Awake and resting EEG conducted on a standard 10-20 system. Background activity is alpha at 9-10 Hz, with bilateral, generalized paroxysmal sharp wave activity. The EEG is suggestive of seizure disorder.

DST:

Age of 12 years was attained, based on parameters of functioning.

ISAA SCORE:

71- indicating mild autism

CBCL:

Mainly overeating and talking excessively and indiscriminately.

VSMS:

Obtained a social age of 8 years and 9 months, with a social quotient of 58, indicating mild deficits in social adaptive functioning.

ICF Neurodevelopmental Disability Assessment

No structural deficits observed and no limitation of function, minimal activity limitation. Mother and Institution proved to be facilitators.

Response To Therapy

As he developed chicken pox, a break in therapy had to be instituted. Improvement in sleep and behavioural problems were reported at the end of the sessions.

Reviewed One Month After The End Of Therapy

His aggressiveness which was already on the mend, was helped by the therapy to calm him down further. He was advised to continue the medication regimen as before.

Categories
Autistic Spectrum Disorder (ASD) Buddhi Stories Epilepsy & Seizures Featured Obsessive Compulsive Disorder

Shanthi – The Time Keeper

Biography

The antenatal period was moderately smooth. Shanthi was born at full term by natural delivery with a birth weight of 3.45 kgs. The birth cry was delayed, with hypoxia and neonatal seizures, and the neonate required oxygen and ventilatory support for a week. By 21 days of birth, she was re-admitted with high fever and respiratory distress with a diagnosis of pneumonia. Bouts of diarrhoea continued till the third year. There was delay in cognitive, language and motor developmental milestones and she uttered the first meaningful word and walked unsupported only at the age of 4. To add to this, she showed autistic-like symptoms of bizarre behaviours and auditory hypersensitivity. Covering both ears, which she repeats often – even while watching a movie on TV – is in all probability a learned behavior linked to anxiety. Children with ASD are known to become fearful of potential unpleasant noises.

Shanthi’s anxiety repertoire extends to strong separation anxiety of a pathological nature, and that may account for her daily ritualistic morning tantrum when she has to attend school. She watches the clock every moment and believes in an obsessive-compulsive manner that her life and the life of her family members revolve around the ticking of the clock. OCD traits are not uncommon in adolescent females with ASD. She awaits her father and elder brother’s return from the day’s work at the expected hour. With even a 10 minute delay, she paces the floor and shortly after, all hell breaks loose! Curiously, she throws a lesser tantrum even if they return from work early, as this disturbs her need for ‘sameness’ and routine.

Shanthi is selectively aggressive and violent at home, beating her mother, the primary caregiver, even without provocation, pinching the elder brother if he switches on the TV without her permission, and breaking objects. While at home, she opposes the figure of authority with screams, when she does not wish to satisfy a demand, bordering on oppositional defiant behaviour but shows remorse when the mother cries.

Attention-seeking, access to preferred items/activities and elimination of demands may be the likely reasons for her to maintain this aberrant behaviour cluster. She has poor self-care skills and is partially dependent on the mother for ADL, especially in areas of personal hygiene.

At school she is a near gem, except for occasionally kicking a classmate for ‘not falling in line’. Then there is the familiar, prolonged holler between class sessions in which she indulges. Her expressive language is poor, but she receives, comprehends and has good retentive power. Immersed in academics, while at school, she has completed two subjects (Science and English) of the Open School Examination with scribe assistance.

With even a 10 minute delay, she paces the floor and shortly after, all hell breaks loose!

Buddhi Notes : Prodigiously Particular

There is little disposition to generalise from these particulars or to integrate them with each other, causally or historically, or with the self. In such a memory there tends to be an immovable connection of scene and time, of content and context (a so-called concrete-situational or episodic memory)-hence the astounding powers of literal recall so common in autistic savants, along with difficulty extracting the salient features from these particular memories, in order to build a general sense and memory. It is characteristic of the savant memory (in whatever spher-visual, musical, lexical) that it is prodigiously retentive of particulars.

Oliver Sacks, Neurologist & Writer on the Savant Brain

Assessment Reports

The Clinical Specialists Observations –

Intact systemic examination. Flaccid tone of all muscles, muscle power 4+, diminished deep tendon reflexes and plantars bilaterally flexor.

EEG Report :

The sleep EEG shows bilaterally symmetrical tall sharp waves in stage 2 sleep. This is an abnormal record.

DST:

Age of 7 years was attained based on parameters of functioning

ISAA SCORE:

73 – indicating mild autism

CBCL:

Externalizing syndrome – aggressive behaviours with co-morbid. Internalizing syndrome – withdrawn/depressed and anxious.

VSMS:

Social age of 8 years and 9 months, and a social quotient of 19, indicating profound deficit in social adaptive functioning.

ICF Neurodevelopmental Disability Assessment

Issues present in mental, neuromuscular and movement areas. No major structural deficits. Significant issues present in the subdomains of learning, applying knowledge, communication, general tasks and demands.

Response To Therapy

Shanthi co-operated for the therapy. Though there was no significant benefit, her mother was pleased with the procedure and requested a longer period of therapy.

Prof. Dr. ESK and the Vidya Sagar team felt that the physical disability status required review, and the Trimed-Neurokrish senior physiotherapist was called in to assess the client. The report reads as follows:

“Normal muscle tone, muscle power 4+, with low endurance. Flat feet with externally rotated lower limb while walking. Atypical gait. Decreased fine motor skills but good gross motor activity.”

The unacceptable behaviours may be explained by the biopsychosocial model of multifactorial risk factors. Structured behavioural modification sessions along with parental skill training may benefit Shanthi and reduce parental stress.

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Autistic Spectrum Disorder (ASD) Buddhi Stories Featured

Isra – Teen Tantrums

Biography

Isra was born of a full term Caesarian section, the indication being cord around the neck. Her weight was 2.7 kgs and her birth cry was normal. There was clear regression of motor, verbal, visuospatial and personal/social domains at 1.5 years with progressive impaired eye contact, temper tantrums and hyperactivity. There was a history of recurrent cough, cold and fever in childhood, and one such episode of high fever with pustules on the skin, at 5 years of age, was diagnosed as *Kawasaki disease and treated. This resulted in further behaviour problems with significant issues in the subdomains of major life areas, communication, domestic life, interpersonal interaction -abusive/ assaultive/ destructive and self-injurious behaviours.

Over the past 2 years, the above traits have peaked and she throws tantrums if her demands are not met, well above what could be dismissed as aberrant adolescent behaviour. Isra has special preferences for certain colours/textures and her express demands can range from a new dress of a particular colour to a pongal/vadai for breakfast. She has an ‘inappropriate attachment’ (as the technical jargon goes) to handwash solution -which she will grab from the table or even from the handbag of the teacher at Vidya Sagar and tuck it away – this is perhaps indicative of a preference for non-social stimuli which provides intense interest in the sensory aspects of the object (and event). She prefers solitary activity in her little corner in the institution and resists if required to transition to another place.

Receptive language is good but she vocalises sparingly. She reads sentences with effort and writes. She has echolalia and repetitive hand movements. At home, she listens repeatedly to music albums that appeal to her on the tablet and is able to crop songs on the computer with ease.

Since her behaviour problems have decreased over the past 2 months, Isra has been selected by the institution to register for the Open School Board Examination, and her first examination is Home Science. She enjoys painting/baking -which are among her five subjects for the course.

*Kawasaki disease may be caused by cerebral vasculitis resulting in patchy ischaemic areas and damage to the central nervous system which may alter neurological function for some time after the acute phase of the illness, with increase in long-term behavioural difficulties. CNS pathology on SPECT is evidence that behavioural changes arise secondary to a cerebral vasculopathy, and are not merely due to the psychological complications of an acute severe illness.

Assessment Reports

The Clinical Specialists Observations –

Behavioural problems for 10 years, intermittent over the past 2 years. Intact systemic examination on General Clinical examination. Neuropsychiatric Inventory revealed psychomotor agitation, dysphoric affect, grossly intact Higher Mental Functions, impaired insight and judgement and no focal deficits.

EEG Report :

Rest EEG taken on a standard 10-20 system shows background activity of alpha waves at 8-9 Hz, mixed with slow waves over the posterior head region. No paroxysmal activity is seen. No increased activity on photic stimulation. The client did not co-operate for eye-opening/eye-closure. A borderline normal record.

DST:

Age of 10 years was attained, based on parameters of functioning.

ISAA SCORE:

85 – indicating mild autism

CBCL:

Internalizing syndrome – withdrawn/depressed, thought problems, attention deficit. Externalizing syndrome – aggressive behaviour, attention deficit, overeating, poor bladder/bowel control.

VSMS:

Social age attained is 4 years and 6 months with a social quotient of 29, indicating severe deficit in social adaptive behaviour.

ICF Neurodevelopmental Disability Assessment

Body function issues are present in mental functions mainly, but no structural deficit observed or reported. Under limitations of activity, significant issues present in subdomains of communication, domestic life, major life areas, interpersonal interaction and relationship. As regards environmental influences, both parents and the institution proved to be facilitators.

Response To Therapy

She was not co-operative for the therapy initially. She was restless and resisting therapy but settled down subsequently. She is currently on Lamotrigine, Risperidone, Haloperido A combination of thyme-leaved Gratiola (Brahmi), Indian Pennywort (Madhukapami), Winter Cherry (Ashwagandha), Clonidine, Atomoxetine, Multivitamin-Multimineral supplements (rich in Vitamin B12, Calcium and Phosphorous).

Reviewed One Month After The End Of Therapy:

With the therapies and the modified drug regimen, Isra has become quieter with a better attention span and improved academics. The mother is the best judge and she is convinced of the palpable improvement in Isra and expresses her wish to continue therapy.

Prof. Dr. ESK suggested looking for any residual clinical and lab signs of inflammatory disease, autonomic symptoms and hip dysplasia to identify the rare possibility of an associated auto-immune disorder. This trend of thought was probably triggered by the acute illness in Anamika’s past history with the diagnostic label of Kawasaki Syndrome which has a close likeness and forms the differential diagnosis for Lupus Erythematosis (LE). LE is an auto-immune disease with periodic behavioural problems and these problems are immensely treatable or controllable. He also suggested maintaining a monthly behaviour chart to check if the immediate premenstrual phase causes increase in the aberrant behaviour pattern.

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Autistic Spectrum Disorder (ASD) Buddhi Stories Featured

David – Comfort in Monotony

Biography

At full term, uterine dystocia and prolonged labour were the indications for birth by caesarean section. The post-natal period was uneventful, except for mild physiological jaundice. It was around the end of the second year, that the parents’ mounting concern about their son not uttering even one meaningful word, took them to the specialist.

David did not respond when called by his name. However, even as a 2 year old, he would run to the TV to hear the familiar TV jingles, which he still seems to relate to every time with the same joy and zest. David was preoccupied with himself, muttered and showed poor eye contact. He was hyperactive and indulged in lone play. BERA (to rule out hearing deficit) and brain MRI (to look for any structural lesions) were done and reported normal. A diagnosis of ASD was arrived at by the specialists.

Special schooling was initiated right away, with emphasis on speech therapy and occupational therapy, and soon he could write numbers and solve basic-level jigsaw puzzles. He has been with Vidya Sagar for the past 2 years. Initially he kept moving around the classroom, with strong intolerance to sitting in one place. He showed no inclination towards academics, except scribbling on paper and favouring the letter ‘H’ and the digit ‘7’ in the letter/number picking exercise. With lack of meaningful words and phrases, David’s self-learning is mainly visual and through observation. He repeatedly grabs a Fevistick with its attractive yellow label or a crayon – preferably green in colour, objects to which he has an ‘inappropriate attachment’ (as tenned in ASD clinical jargon). ‘Sameness’ seems to be his comfort zone. When asked to return the object – being of easy and flexible temperament -he returns it without a whimper, only to grab it the next moment. Occasionally he has to resort to tantrums to get his way, when caregivers seem unreasonable!

With physical exertion in the dance class, his restlessness has been brought under a semblance of control and with this his attention span has shown improvement. Attention is the first step towards learning and the child shows some progress in activity-based learning, as he sits through longer sessions with undivided attention. His restlessness continues to manifest as hand flicking and whistling intermittently.

Assessment Reports

The Clinical Specialists Observations –

A general clinical examination showed an intact systemic examination. The Neuropsychiatric Inventory revealed increased motor activity in the classroom, unintelligible sounds by way of speech, grossly intact higher mental functions and no focal deficits.

EEG Report :

Bilateral Epileptiform Dysfunction

DST:

DST age of 3 years attained

ISAA SCORE:

94 – indicating mild autism

CBCL:

Internalising Syndrome Criteria for withdrawn/depressed, social problem and attention deficit.

VSMS:

Social age of 5 years, 4 months and 8 days obtained with a social quotient of 70, indicating borderline deficits in social adaptive functioning.

ICF Neurodevelopmental Disability Assessment shows minor problems in mental function, and no structural deficit. Under activity and limitation, significant problems in subdomains of learning and application of the gained knowledge, general tasks and demands, self-care, major life areas and community, social and civic life. Considering environmental factors, both parents and institution prove to be facilitators.

Buddhi Notes : A Curious Attachment

One of the most outstonding symptoms of the autism spectrum is a curious attachment to objects. Perhaps part of a tendency to over-invest in certain activities, at the expense of other “more normal” pursuits, such attachment can traverse the gamut of inanimate objects. On occasion, such attachment can be to a particular activity or even a particular person. I recall an interesting article by a doctor in the Journal of the American Medical Association titled “Phantom of the Opera” in which she described her son’s attachment to a particular piece of music and need to hear the same, over and over again. Curiously, attachment to certain objects (such as a teddy bear, even one that is moth eaten or mangled) is a transcultural childhood trait. Remember Mr. Bean and his companion bear, anyone?

Prof. Dr. Ennapadam S. Krishnamoorthy

Response To Therapy

David co-operated overall for the therapy except for some restlessness in the second session. At the end of therapy, the overall improvement was significant. His mother wished to continue therapy.

Reviewed one month after the end of therapy, his motor movement and co-ordination were better, and his repetitive movements reduced. His attention span has improved and he responds better to classroom activity. David has anger outbursts when pushed by his brother, which was considered a natural response to the provoking stimulus and was viewed as a positive sign, both by the Trimed-Neurokrish team and the senior faculty of the institution.

Prof. Dr. ESK suggested introducing AED medication with the consent of the parents.

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Anxiety Autistic Spectrum Disorder (ASD) Buddhi Stories Featured Neurodevelopmental Disability (NDD)

Surya – Conquering Anxiety

Biography

Surya was the first born, delivered full term by lower segment Caesarian section, the indication being a big baby weighing 3.4 kg with a large head and cephalo-pelvic disproportion. The Apgar score was 9/10 (excellent). There was no neonatal seizure or any other health-related event of significance in the neonatal period or in infancy. With the passage of a few months the parents noted that the infant’s response to familiar people, even to them, lacked spontaneity, and eye contact was sparing. He was preoccupied with repetitively examining one favourite toy over a long period of time and this form of restricted play continued into childhood. He did not walk till almost 2 years, and even when he did, he was awkward and had frequent falls in the early phase. It was, however, the delay in the speech/language milestones with the first few meaningful words expressed at 2 years, that caused greatest parental concern.

At this stage, a diagnosis under the broader umbrella of Autism Spectrum Disorder (ASD) – Pervasive Developmental Disability – not otherwise specified (PDD-NOS) was arrived at by the specialist in USA and early therapies were started. The parents stuck to the specialist advice to confine the child’s exposure to a single language and English served the school and home front. On joining school at three years, there was some improvement in his verbal expression, but by 4 years, with the family back in India, from abroad, he had achieved wider language and communication capability. This is the magic gift that Indian children born abroad receive on exposure to the Indian milieu, even short-term, where grandparents, aunts, uncles and cousins, chatter incessantly, not necessarily in English, but also in their child-focused affection, rally round to address the child face-to-face!

Exploring the Condition

Surya’s speech, which lacked clear enunciation, accent and prosody, and had a nasal quality, required special attention and the child had regular speech therapy from the age of 4 years, aside from occupational therapy and special education outside mainstream schooling. Surya manifested restlessness, easy distractibility, poor motivation, social anxiety and on occasions, impulsivity, which also required correction. When he was brought by his parents to TriMed-Neurokrish two years back, at age 9 years, they appeared as stressed as Surya himself. As a high performing ASD, he had managed to barely cope with mainstream schooling upto the primary grades (ICSE Board syllabus), with poor math skills and dyslexia. Anxiety was mounting as he progressed to high school level with its academic demands. To add to the displeasure at school, he was bullied by the other children, who did not let him join them in the ball games offered, as he was slow and clumsy. When this awkwardness was analyzed by the specialist, it pointed to poor hand-eye co-ordination as a main cause. School refusal started to set in and the parents recognized the red flag signal which called for more intensive professional attention. A close friend suggested TriMed-Neurokrish as a possible solution to the child’s learning disability and emotional  problems.

Surya had got this far academically, without major behavioural problems, as all along, the mother had dynamically participated in fulfilling his study requirements and emotional needs and the school had been supportive. His mother, a well educated, perceptive lady, continued to follow the special education methods at home, which she observed during the child’s sessions with the special educator. His spelling skills took a big leap forward when he was taught by the phonetic method. The mother spent long hours with Surya over his homework, partly by following rote learning methods, though by elaborating on the topics’ ramifications, she managed to bring in some conceptual learning, which ensured better retention and recall in him. Math skills were just picking up at a basic level, but Surya was happy to run up to the corner store to purchase some small items of grocery the mother requested, and managed every time to bring back the correct change.

Our Healing Approach

At TriMed-Neurokrish, a comprehensive assessment, by the team members was carried out with meticulous care. The child was thin built, with dysmorphic features, with a narrow face, low set ears, close set eyes, and a tendency to keep the lips parted slightly, the last due to a chronic sinusitis and nose block. No other abnormal systemic signs were observed and laboratory tests were unremarkable, except for low D3 levels, which was corrected with oral medication. We had a team meeting to formulate a list of priority moves to gain effective control in the management of Surya’s educational and psychosocial problems. A diagnosis under High functioning Autism Spectrum disorder – Pervasive Developmental disorder not otherwise specified (PDD-NOS)/Asperger’s syndrome (based on the Sohn Grayson Rating Scale) with Learning Disability (LD) was arrived at, and the broad management plan was discussed.

The immediate goal was:

  • To reduce Surya’s anxiety levels and get him to attend school regularly, a few hours initially, progressing to full day attendance
  • To overcome separation anxiety when the mother dropped him at school and left
  • To motivate him to engage in other activities than studies
  • To work on his fears and phobias of ‘robbed’, ‘kidnapped’, ‘killed’ which disturbed him
  • To offer caregiver support to the mother who was highly stressed

By way of medication, Surya was given Attentrol – (Atemoxitine) to improve his attention on tasks along with a anxiolytic.

The Clinical Psychologist found his academic performance adequate, based on the NIMHANS Battery (Specific Learning Disability Index). Regarding his special academic needs, with long term coaching outside school, Surya was able to cope with reading, writing (including spelling), at his 8th grade levels, with math ability at 5th grade levels. His handwriting skills were poor due partially to defective fine motor control and his focusing power on tasks required reinforcing with repetition. All these deficits put together made him very anxious regarding coping with studies.

Our intensive therapy for Surya followed our protocol for children with Neurodevelopmental Disorders (NDD) and included a combination of two Ayurveda treatments (Shirodhara & Abhyangam), Play Yoga, Neurodevelopmental Therapy (NDT, a combination of physical and occupational therapies, in his case with a handwriting focus) and psychological therapy (behavioral and family). Sessions of NDT and BT often continue for months in regular periodicity, and include weekend opportunities to meet with peers (also in therapy), socialize, and develop skills of emotional expression. Later, understanding his fondness for ‘gadgets’ we involved him in a cognitive enhancement program using structured computer based gaming to enhance specific cognitive skills.

Our team, after much deliberation, suggested to the parents, special education for Surya at a school of excellence, and with the Open School Examination system offered there, he settled to a comfortable pace of school work.

The special educators of the school, in dialogue with Surya’s parents, chose subjects for him that he would be able to comprehend and work out in a relaxed manner, and which would lead him to a future career as a high performing ASD. In this more relaxed school environment, the child overcame his fears and the separation anxiety was no longer a problem. Day-to-day, moment-to-moment caregiver stress was significantly reduced in the mother, who decided to expose Surya to other activities than studies as suggested by the TriMed-Neurokrish team. Coaching in swimming and keyboard playing were chosen as two diverse activities (with the mother joining the coaching sessions as well) which would benefit physical fitness, cognitive ability, concentration, fine motor activity, musical sensitivity, sensory integration and many other finer aspects of development in the child.

Surya’s motivation and empathy to go with the mother did not last for long and the ASD trait of preference for routine and repetitive activity prevailed. He preferred to unobtrusively sit watching his mother, as she completed the courses successfully and went on to the next level of training with the hope that perhaps Surya would get back to these activities some day with gentle persuasion and the slow but sure outcome of goal-directed CBT! She brushed aside this wishful thought and got back to the present with its encouraging progress in Surya.

He was however, enjoying his Behaviour Therapy and Cognitive Enhancement sessions at Trimed-Neurokrish and the team members gave of their best to sustain Surya’s interest through the sessions. He continued to listen to music, most often a favourite tune and beat repeatedly. He responded positively to engage in a short-term novel activity for which he was rewarded. In a BT session to learn how to tie his shoe-lace, his motivation was that he would get new shoes, and sure enough he mastered the skill in two days! What worked towards motivating Surya without fail was the reward in the form of a car ride, to undergo any new learning process. So the team went through BT for activities of daily living, interaction with strangers, mentoring and token economy, in a graded manner, to more advanced cognitive enhancement paradigms of arithmetic tasks, logical reasoning and critical thinking. Incorporating the subject’s areas of special interests in therapy, using visual aids and including parents in therapy sessions, the benefits of cognitive behavior therapy and cognitive enhancement became apparent.

“In this more relaxed school environment, the child overcame his fears and the separation anxiety was no longer a problem.”

Our Focus:

Autistic Spectrum Disorder

Autistic spectrum disorder (ASD) is a group of developmental disabilities that can cause significant social, communication and behavioral challenges. Autism represents an unusual pattern of development beginning in the infant and toddler years. Language  and communication, learning, thinking, problem solving, social interaction, stereotypy and other behavioural  patterns, lack of empathy and performance of activities of daily living may show varied levels of involvement. Neuropsychiatric and neuropsychological evaluations in Autism have revealed selective dysfunction of ‘social cognition’, with sparing of motor, perceptual and basic cognitive skills1. According to DSM IV the spectrum of autistic disorders comprise autistic disorder, Asperger’s syndrome, pervasive developmental disorder not otherwise specified, including atypical autism (PDD-NOS), Rett’s syndrome, and childhood disintegrative disorder. When full criteria of the five under this umbrella are not met, it falls under the category of PDD-NOS. High functioning Autism Spectrum disorder – Pervasive Developmental disorder not otherwise specified (PDD-NOS)/Asperger’s syndrome is diagnosed by employing an assessment questionnaire for the subject’s parents named the Sohn Grayson Rating Scale, a questionnaire for the subject’s parents, covering the academic, cognitive, psychosocial and other domains, which may indicate a higher performance and atypical pattern of the spectrum in the subject studied, as in our patient, Surya. Before this instrument is used, there are over seven diagnostic tools for ASD, including Autistic Behavioural Checklist, Autistic Spectrum Screening Questionnaire and observational tools which must be employed on subject to be tested.

Global prevalence of ASD is about 1.5 per 1000. There has been a 600% increase in prevalence over the last two decades. In a multinational study, the point prevalence of ASD was 7.6 per 1000 or 1 in 132 in 20102. In India more children with ASD are being identified, earlier than before and as a result, early intervention is possible with developmental disability institution being made available in the public sector as well. But these are few and far between. The average age at presentation to the clinic in India was 21.23 months (SD = 2.18)3. They present clinically in a manner similar to that reported internationally. Awareness among professionals and the public is increasing over less than a decade.4  As yet, there is no aetiology-based intervention for autistic spectrum disorders (ASD). However, symptomatic treatment and therapies with a cognitive-psychoeducational/behavioural approach  can be of value in moderate ASD5.   

References

  1. Vaghbatta. Shirodhara AshtangaMisra V. The social brain network and autism. Annals of neurosciences. 2014 Apr;21(2):69.Hridaya, Sutra Sasthana, Chapter 22
  2. Baxter AJ, Brugha TS, Erskine HE, Scheurer RW, Vos T, Scott JG. The epidemiology and global burden of autism spectrum disorders. Psychological medicine. 2015 Feb 1;45(03):601-13.Ajanal Manjunath, Chougale Arun Action of Shirodhara– A Hypothetical Review J Res. Med. Plants & Indigen. Med. Sept. 2012 1;  9 : 457–463
  3. Malhi P, Singhi P. A retrospective study of toddlers with autism spectrum disorder: Clinical and developmental profile. Annals of Indian Academy of Neurology. 2014 Jan;17(1):25.
  4. Malhotra S, Vikas A. Pervasive developmental disorders: Indian scene. Journal of Indian Association for child and adolescent mental health. 2005;1(5).
  5. Francis K. Autism interventions: a critical update. Developmental Medicine & Child Neurology. 2005 Jul 1;47(07):493-9.

Looking Ahead

Surya is relaxed in his new school, and stress and anxiety of school work has left him. He is catching up with many ADL, and is even more motivated to do so with a reward at the end of each novel learning process. With improved performance and by dispelling his fears and phobias through logical thinking taught to him at the CBT sessions, Surya has conquered many of his fears and phobias and to a considerable extent his social anxiety.

He continues his CBT/CET and follow up at Trimed-Neurokrish, twice a week and the team is more than pleased to receive him for his sessions, as there is good compliance and palpable progress with each visit to the clinic.

The parents are at peace and are relieved to have found a centre which offers a holistic approach towards Surya’s all round development.

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Autistic Spectrum Disorder (ASD) Buddhi Stories Depression Featured

Ragini – Her Uphill Battle

Biography

It was a full term natural delivery. The newborn was small at 2.7 kgs. There was no complication of pregnancy and mother and infant were well. Motor milestones followed a normal curve, but language was delayed till the age of five years. Strangely, musical expression preceded language and by 2 years 6 months, Ragini lisped in melodic sequences, as melody with lyrics came with ease. She belonged to yet another traditional south Indian family where music occupies the whole day, from the TV devotional music broadcast at the break of dawn, the bathroom singing by the father relaxing through an evening lukewarm shower after the day’s work, till into the night, when the mother sings the infant to sleep – that ‘soporific lullaby’ which never fails! However, nurture alone cannot explain the child’s musical ability, which advantage she carried without losing ground, into adolescence and adult life with formal vocal classical music instruction. The family being resident in the West, she received higher grade training in Western classical music as well and got into the stride of it with no extra effort.

Exploring the Condition

Ragini had poor communication skills, sub-average intelligence on the Wechsler Intelligence Scale for Children (WISC), language processing difficulty, perceptual thinking deficit and social fears and phobias when examined in childhood. She became irritable and frustrated, as coping with routine stresses, given her condition, became increasingly difficult over the years, and she showed significant disruptive behaviour at about 10 years of age by way of aggression. Following a psychiatric assessment, she was started on Tab. Risperidone, an atypical antipsychotic to control the irritability of the Autistic Spectrum Disorder (ASD) and to reduce her depression. She continued Risperidone till the age of 19 years, went through mainstream schooling, as she was a high functioning ASD, and successfully completed a Certificate Course in Vocational training.

In 2013, Risperidone had to be withdrawn, due to tardive dyskinesia, and Clonazepam SOS was prescribed. Two years passed peacefully, off medication. With the support of her well educated, discerning parents empathetic to her needs, Ragini established her own space in her music studio,  where she could listen to music, catalogue the music videos in her collection  in the studio library, and even give musical training to groups. All this was encouraged by her parents, mindful of her problems as it also represented an attempt to organize herself into some self employed music-related career, in an area closest to her heart. However, largely alone in the studio also left her isolated and socially withdrawn. Perhaps due to this a feeling of helplessness, hopelessness and worthlessness descended upon her, and she had suicidal ideation. She was emotionally sensitive, eager to please, but did not have the ability to take criticism. Symptoms that started insidiously, reached a peak within 6 months, in mid-2015. She became severely depressed.

Escitalopram (antidepressant) and Quitiepine (an atypical antipsychotic) prescribed by the psychiatrist could not bring about any control. After a further 5 months of rapid mood swings, crying, shouting, explosive episodes of dyscontrol and threats of leaving home, the mother brought Ragini to India, hoping that a change of environment would help in some way to ease mounting family tensions. She had information about the multidisciplinary approach and integrated therapy offered by TriMed-Neurokrish and fixed an appointment for Ragini.

Our Healing Approach

It was not easy for the team at TriMed-Neurokrish to thaw the ice and make Ragini accept that the specialist team was there to help her. Once this was achieved even partially, with gentle persuasion, the flow of the assessments became smoother, with cooperation from the patient. The diagnosis and plan of management fell in place with the detailed clinical history of events that led up to the mental state at the time of assessments and clinical examination.

Her Rorschach Inkblot test produced 22 responses, meeting the perceptual thinking and coping deficit index. She had severe depression and a feeling of worthlessness. EEG showed significant epileptiform activity without localization or lateralisation. She had a past history of episodes of stare with momentary loss of consciousness. Blood test and MRI/MRA brain were unremarkable.

The Diagnosis was Autistic Spectrum Disorder (High Functioning) with Rapid Cycling Affective Disorder and Episodic Dyscontrol Syndrome. Arriving at a suitable drug regimen was more difficult and prolonged, with loss of precious time, as 2 anticonvulsants used as thymoleptic agents had to be rejected as Oxcabamazepine produced a moderate allergic response, and even worse, Lamotragine produced a Steven Johnson’s type adverse drug reaction. After allowing time for recovery from these drug reactions, the patient was stabilised on a drug regimen which she tolerated well, along with an extended program of therapies running parallel.

The regular medication was

  • Lithium (sustained release) 400mg – 1/2-0-1
  • Olanzapine 10mg – 1/2-0-1
  • Escitalopram 1-0-0
  • Lorazepam 2mg – 0-0-1
  • Vitamin supplements

The mood stabilising, antidepressant and anxiolytic effect of this drug combination was reinforced with 24 sessions of CBT, individual psychotherapy and family education, 11 of physiotherapy (grade 2), 34 of Acupuncture, 20 of Reflexology, 34 sessions of Shirodhara and whole body massage and 24 sessions of Yogasana, intensive and daily over the initial phase and then spaced out to 3-4 days a week.

“There is considerable evidence suggesting that a subset of Pervasive Developmental Disorder (PDD), youth with extreme disturbance of mood suffer from a symptom cluster that is phenomenologically consistent with the syndrome of Bipolar Disorder (BPD)”

Joshi, 20091

Longitudinal studies are essential for observing the onset and progression of co-morbid condition of Bipolar disorder in ASD.

“It is of importance to recognise both the psychiatric diagnoses of ASD and overlapping BPD in order to plan the drug regimen, therapies and set realistic treatment goals.”

Looking Ahead

Following the extended therapy program and after being stabilized on the drug regimen, there is a definite return of Ragini’s lost self esteem, which had been shattered during the downhill phase. Her mood swings are minimal, and there is no episodic dyscontrol. The mother admits that she came with the hope of some relief of Ragini’s symptoms of aggression and dyscontrol. She got much more from the team at TriMed-Neurokrish, she confessed, and feels that the situation is under control and has the hopes to settle her daughter’s future plans of home and career within reasonable goals.

Categories
Autistic Spectrum Disorder (ASD) Featured

Overcoming Autism with Growing Brain Lab

Disorders of brain and nervous system development are among the most disabling disorders that  affect young children and their families. These include several forms of mental   retardation and learning disability, cerebral palsy, dyslexia, autism, attention   deficit and hyperactivity disorder and a spectrum of motor, cognitive, behavioral and emotional   disorders including those due to family and school stress.

Autism is one of the most important disorders that affects young children. Autism is known as a ‘spectrum disorder,’ because the severity of symptoms ranges from a mild disabilities in learning, language development and social interactions to a severe impairment, with multiple problems and highly unusual behavior. The disorder may occur alone, or with accompanying problems such as mental retardation or seizures. Autism is not a rare disorder, being the third most common developmental disorder, more common than Down’s Syndrome. Typically, about 20 in a population of 10,000 people will be autistic or have autistic symptoms. 80% of those affected by autism are boys.

Children with Autism need the care and attention of a multi-disciplinary team, including the paediatrician, neurologist, psychiatrist, physical, occupational and speech therapists,   psychologists with special training and interest in education and development,   special educators, social workers, speech therapists and nurses.  At present, there is no pharmacological therapy which can cure autism. The only consistently effective treatment for autism is a structured training program; therefore, a combination of a good school and parent training is the best known treatment. Autistic children can make significant progress if the intervention is appropriate and consistent.

Growing Brain Lab (GBL) is an innovative project at Neurokrish-Trimed.  Over a decade GBL has evolved as multidisciplinary model of assessment that addresses Learning,   Aptitude and Behaviour across motor, cognitive, emotional, and psychosocial   domains. GBL has also perfected in this timeframe a model of after-school   therapy incorporating behavioral management and Neurodevelopmental therapy.   With the advent of TRIMED and it’s integrative approach, GBL now incorporates seamlessly a range of holistic interventions targeting symptoms of various developmental disorders including Autism. Play Yoga, Mud Therapy, Reflexology, Ayurvedic Therapies all blend seamlessly into a whole in the TRIMED-GBL program. Inspired by excellence and Success Stories, GBL is today making accessible to families, modern healthcare with ancient wisdom, which is the TRIMED mantra.